Reconsidering the reductions of medical education

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Angela Chen Professor Kate Mason ANTH 0300 Culture and Health 13 May 2021 Reconsidering the reductions of medical education The medical profession is one timelessly lauded and sanctified in the public conscience, surrounded by an intricate, opaque network of rite and culture that fundamentally separate the medical practitioner—or the aspiring one—from the habitus of those outside the medical field. Although perceivably necessary to induct aspiring medical workers into the medical field, the medical-school-to-residency pipeline is by report often debilitatingly rigorous, rife with power disproportionality, and systemically callous against students’ physical and psychosocial vulnerability. These problem areas multiply with racial and sexual inequalities, impacting intersectional minorities, such as immigrant students of color. The infrastructural, racialized dismissal of the personhood of both healer and patient fosters an active negligence of biopsychosocial holism in modern curative medicine, undergirding short-term and long-term issues with the growing rift between fixing and curing, and an increasingly reductive gaze of the patient as an individual. Through a conceptual reevaluation and systemic renovation of the medical education and residency system to promote real, humanistic caregiving, the American medical system can be optimized to protect and care for both healer and patient. To properly dissect the current practical limitations of the Western healthcare system, we must trace the cultural provenance of its central woodworking—the biomedical model, a product of 17th-century Baconian natural philosophy that affirmed an “objectified conception of nature” and saw the world as a neutralized, phenomenal domain designed for estimation and mechanical manipulation (Davis 35). Stemming from this new attitude towards scientific exploration was a strict biologism and procedure-oriented, instrumental pursuit of knowledge with its direct practical and prescriptive value. Translated to healing, this value system idealizes medicine, usually an illusory biomedical magic bullet, which isolates the clinical and situational complexity of the illness experience into a limited quantity of principles and targets (Davis 44). Effectively, this reduced the human body into a digestible network of moving parts and pathologies, each of which can be distinguished and ostensibly treated in isolation. The modern medical system has thus inherited this course characterized by biomedical reductionism, mechanical explanations for phenomena, and an overreliance on technological solutions to treat fundamentally human illnesses. Against this prevailing macro-culture, more holistic, social-oriented and integrative approaches towards healing have been for the most part unable to sustain significant traction. This radically reductive attitude towards human health is sustained by the medical education pipeline that establishes an esoteric, staggering system of rites and requisite knowledge around medicine, constructing doctorhood as a separate world with its own specialized methods of “seeing, writing, and speaking” (Good 70). In Professor Byron Good’s recount of his experience teaching at Harvard Medical School, the first two years of medical education centered on learning the biomedical sciences—an amalgamation of histology, gross anatomy, and radiology labs that initiated a sweeping reconstruction of the human body into “infinite, hierarchical detail” (Good 72). The individual becomes a body lifted out of its normal context—a site of mining medical knowledge in the same way the biosphere is of scientific knowledge to the naturalists. The anatomy lab becomes a ritualistic, transgressive space where the human body is phenomenologically reconstructed into assessable units, entered clinically and operated on according to an entirely new moral code. Medical students adopt not only what Foucault termed the medical gaze—to appraise individuals as bodies rather than people—but also a separate mode of interaction with the world, a rigorous and “dialogical medium… of encounter, interpretation, conflict, and at times transformation” (Good 86). In an interview, Mingwei Chen, an internal medicine practitioner at Duke Hospital, addressed her experience matching for residencies: “I had to take the USMLE (United States Medical Licensing Examination) at age 39, around a full 18 years after graduating from medical school. Starting in 2010, eight hours a day for two years, I put in my absolute best studying for this exam. It was easily the most difficult time of my life. I felt myself turn almost fully into a machine” (Chen). Throughout the med-school-to-residency pipeline, aspiring doctors are made to overwork themselves, dismiss their health and limitations, to adapt to a new, demanding order of being. And often, this induction into the hidden curricula of the medical world indicates conceptual and physical “hazing” that forces medical students and interns to deprioritize the personhood of both themselves and patients—whilst struggling through a debilitatingly high workload, long hours on call, and grueling mentorships (Smith-Oka 82). This mechanization of intern workforce and systemic dismissal of human limitation in a rigorous hospital environment are reinforced in the way doctors are conditioned to oversee the socio-behavioral complexities of their patients in favor of apprehending them as a medical issue or scientific object—exactly the biomedical reductionism that the current framework promotes. The hierarchies of hospital residencies are rife with generational power imbalances that reinforce deeper societal inequalities stemming from race, gender, and class differences—being an intersectional minority under infrastructure designed to accommodate only one dominant class feeds further into the traumatic deidealization that occurs over the course of health education. These relevant enterprises have not fundamentally changed how we care for the external and internal wellbeing of patients, select for future care providers, and appraise our learners, especially with a gross inequity in representation across race, ethnicity, gender, and class. Dr. Chen, a Chinese-American immigrant, recounts how she could not comprehend a single line of spoken English in the Detroit airport when she first arrived in the U.S. to continue her medical education. She cites a profound financial instability, high cultural barriers, and struggles with naturalization as the greatest difficulties in her acclimatization to her education and, later, her profession—all of which causes are endemic in immigrant or first-generation medical students of color. “I immigrated to America not explicitly wanting to study medicine—it was more that I saw the opportunity for economic mobility and took it. I was in survival mode; I had to make a stable life for myself here. I barely knew the language and was learning scientific English at the same time I was self-studying organic chemistry. We all knew the USMLE exam prioritized English proficiency, so the judgers often were biased towards South-Asian, usually Pakistani test-takers—their English was generally better. I felt all the odds were just piled against me” (Chen). Inherent within health profession training and medical education is the assumption of English proficiency and American birth. Immigrant applicants are thus often at a disadvantage, needing to adapt not only to the conceptually novel language of medicine, research, and experimentation, but also the English tongue in and of itself. This is effortful and disadvantaging with verbal exams such as the MCAT, to go to medical school, and the USMLE, to participate in a residency—whilst working towards situationally unique objectives such as a green card or permanent working permit—that engender higher rates of depression, anxiety, and ostracization across chronically underserved immigrant student populations. Chen lists “luck, opportunity, and effort” as what ultimately guided her to professional stability—“but more so the former two” (Chen). More for immigrant and first-generation students than ever, the progression from school to clinical residency is risky and uncertain at every juncture, easily instilling a sense of helplessness that comes intrinsically from situational differences out of one’s control. This seemingly insurmountable cultural and language-based distance, without the appropriate systemic resources to instigate a bridging or integrative effect, can also jeopardize human rapport and sterilize the doctor-patient relationship down to the biomedical objective. The gross underrepresentation of minority races such as black or Latino in the health care workforce both during and following postgraduate internship training is both a symptom and a roundabout result of the system’s failure to accommodate the multilingualism and ethnic plurality. At an individual level, students underrepresented in medicine or who belong to part of a minority group are more susceptible to poor health, heightened stress, and anxiety, and are likelier to self-report that their race or ethnicity adversely affected their experience in medical training (CITE). In her personal essay on the racism that she encountered in medical school, Taiwanese-American physician Michelle Ko recounts microaggressions that Black and Latinx students habitually face—mockery for tokenism, skepticism on the authenticity of their achievements, all complicit in a system that allows for a stratified hierarchy designed to pit minorities against each other (Ko 1087). Ko expertly argues that the race-specific mass stereotyping of a certain group can heavily influence not only the way they are perceived by the community they serve, but their professional performance as well. For instance, the model minority stereotype—originally a defense mechanism against Asian-Americans’ outsized presence in the medical field, weaponized to proliferate a patronizing image of them as docile and undeserving of activism—has evolved to accuse Asian-Americans of being hyper-fixated on the quantitative (i.e., grades, achievements, performance) over the qualitative (i.e., humanity, community, group morale). Ko cites multiple studies that indicate Asian-American medical students are thus likelier to be judged by faculty as “less kind and compassionate” (Ko 1088). This oblique, group-specific racism can often be internalized by members of that group, effectively fulfilling itself in their relationships with their patients, in which they present themselves as expectedly removed or distant. The dominant, oppressive culture of mechanical reductionism is enabled not only simply by the medical education and residency system, but more evidently by its inability to equally accommodate students varying in race, class, gender, and birth—and thus its failure to stem the cultural distance minorities may feel from their work. This reveals a self-reinforcing system as unable to accommodate the fullness of personhood of both healer and patient, when its ultimate goal has always—and will always remain—to treat people. It proves difficult to take the pulse of problems so invisibly pervasive in the current medical system, delineate them, and design targeted solutions; it runs after all counterintuitive to the essay’s mission in revealing the debilitating inadequacy of biomedical reductionism in medical practice. This essay calls for an extensive, equity-based remodeling of the medical education system. Instead of purely resorting to implementing diversity-training workshops and equity education as separate programming, which can inadvertently reaffirm racial biases, Ko calls for all research and medical education institutions to “restructure their admissions, curricula, and training programs with a foundational commitment to serving communities with the greatest needs” (Ko 1090). Short-term policies like a systematic gradation of intern workload, a streamlining of hospital mentorship systems, and a diversification of test-taking options for exams are valuable to consider, but on the long term, it is essential for medical schools and institutions to adopt a permanent mission for health equity. When organizations are encouraged to apply themselves towards promoting the lives of the underserved in a racially and ethnically structured society, issues of disproportionate representation in education—alongside its pernicious consequences—will phase out. Whether this be increasing supportive infrastructure available to first-generation medical students, or implementing a more humane labor and accountability system in hospitals, the foremost attention paid in policy-making to patients and caregivers as people will bring about a subtle but definitely cultural change that gathers the units of human bodies back into holistic individuals.

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